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Facial surgery (FFS)

Facial feminisation surgery (FFS) is a collective term for surgical procedures that feminise facial features. It essentially involves bone surgery on the head, combined with procedures on soft tissues. The great majority of these procedures are irreversible: bone that has been flattened or sawn down does not grow back.

What FFS exactly involves

Common procedures are frontoorbital remodelling (grinding down or remodelling the brow bone ridge, often with opening of the frontal sinus), hairline lowering (shifting the hairline with a scalp incision), rhinoplasty (nose correction), jaw-angle reduction (sawing parts of the lower jaw), chin narrowing (osteotomy of the chin) and tracheal shave (reduction of the Adam's apple via an incision in the neck). For the patient the package 'FFS' feels unified; medically these are very different procedures, each with its own risk profile.

Risks and complications

FFS procedures are major surgery. Possible complications include: nerve damage with lasting numbness or asymmetric facial expression, infection (including of the frontal sinus after frontoorbital remodelling), haematoma, poorly healing bone sites, alopecia around the hairline scar, prolonged swelling that can last months to a year, and a cosmetic result that differs from expectations. Revision surgery is possible but further weakens tissue and can rarely fully restore what was removed in the first procedure.

Irreversibility

Bone that has been ground down or shortened does not come back. A person who later regrets or detransitions keeps the remodelled facial structure. The same applies to tracheal shave and, to a lesser extent, soft-tissue procedures. This aspect deserves more attention in informed consent than it often gets in practice.

FMS for trans men

For trans men there is facial masculinisation surgery (FMS), in which more pronounced masculine features are created instead. FMS is less common and less often reimbursed. The physical effect of testosterone on the face (fat redistribution, beard growth, sometimes a more pronounced jawline) is generally more pronounced than that of oestrogen, so that the need for surgical masculinisation is felt to be smaller.

Reimbursement in the Netherlands

Some FFS procedures are reimbursed when judged medically necessary within the gender care pathway. In practice much is not reimbursed, and people turn to foreign clinics because of costs, waiting times or available techniques. Foreign clinics vary widely in quality and offer few aftercare possibilities for complications back in the Netherlands.

What about 'passing' and well-being?

Some studies suggest that FFS increases reported satisfaction and social 'passing'. The methodological quality of that research is generally weak: short follow-up, no control group, self-selection of satisfied patients. Moreover, there is an uncomfortable reasoning behind the idea that FFS is necessary — namely, that social acceptance depends on meeting gender norms about appearance. That is neither self-evident nor a neutral medical fact. See also Gender norms.